| NPI | 1194072348 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: KY D-00167) |
| Additional Taxonomies | 122300000X Dentist (Licence: MI 2901020670) |
| Enumeration Date | 2012-08-07 |
| Last Update Date | 2026-09-10 |